Pub Date : 2018-10-01DOI: 10.1093/med-psych/9780195370607.003.0003
M. Zanarini
This chapter reviews the findings of 17 small-scale prospective follow-up studies of the short-term course of BPD. It also reviews the findings of four large-scale follow-back studies of the long-term course of BPD. The results of these small-scale prospective studies have been taken to mean that most borderline patients are doing relatively poorly a mean of one to seven years after study entry. The results of these large-scale follow-back or retrospective studies, which diagnosed subjects by chart review, found that, on average, subjects were doing reasonably well a mean of 14–16 years after their index admission. The strengths and limitations of these early studies of the course of BPD will be reviewed, as well as detailed findings from each study; findings pertaining, where available, to the symptoms of BPD, co-occurring disorders, psychosocial functioning, and psychiatric treatment.
{"title":"Earlier Studies of the Longitudinal Course of BPD","authors":"M. Zanarini","doi":"10.1093/med-psych/9780195370607.003.0003","DOIUrl":"https://doi.org/10.1093/med-psych/9780195370607.003.0003","url":null,"abstract":"This chapter reviews the findings of 17 small-scale prospective follow-up studies of the short-term course of BPD. It also reviews the findings of four large-scale follow-back studies of the long-term course of BPD. The results of these small-scale prospective studies have been taken to mean that most borderline patients are doing relatively poorly a mean of one to seven years after study entry. The results of these large-scale follow-back or retrospective studies, which diagnosed subjects by chart review, found that, on average, subjects were doing reasonably well a mean of 14–16 years after their index admission. The strengths and limitations of these early studies of the course of BPD will be reviewed, as well as detailed findings from each study; findings pertaining, where available, to the symptoms of BPD, co-occurring disorders, psychosocial functioning, and psychiatric treatment.","PeriodicalId":275647,"journal":{"name":"In the Fullness of Time","volume":"1 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"131351576","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2018-10-01DOI: 10.1093/med-psych/9780195370607.003.0008
M. Zanarini
Self-mutilation and help-seeking suicide threats and attempts are among the few almost pathognomonic symptoms of BPD. This chapter assesses predictors of self-harm and reasons for self-harm over time. It also assesses predictors of suicide threats and attempts over the years of prospective follow-up. Each outcome has a different set of multivariate predictors, but some appear in several multivariate models. More specifically, sexual adversity in childhood and adulthood, major depression, and severity of dissociation are predictors of self-mutilation; and sexual adversity in adulthood, major depression, and severity of dissociation are predictors of suicide attempts. However, these factors do not play a role in predicting suicide threats. Instead, two dysphoric affective states and two outmoded interpersonal survival strategies are the best set of predictors of suicide threats.
{"title":"Prevalence and Predictors of Physically Self-Destructive Acts over Time","authors":"M. Zanarini","doi":"10.1093/med-psych/9780195370607.003.0008","DOIUrl":"https://doi.org/10.1093/med-psych/9780195370607.003.0008","url":null,"abstract":"Self-mutilation and help-seeking suicide threats and attempts are among the few almost pathognomonic symptoms of BPD. This chapter assesses predictors of self-harm and reasons for self-harm over time. It also assesses predictors of suicide threats and attempts over the years of prospective follow-up. Each outcome has a different set of multivariate predictors, but some appear in several multivariate models. More specifically, sexual adversity in childhood and adulthood, major depression, and severity of dissociation are predictors of self-mutilation; and sexual adversity in adulthood, major depression, and severity of dissociation are predictors of suicide attempts. However, these factors do not play a role in predicting suicide threats. Instead, two dysphoric affective states and two outmoded interpersonal survival strategies are the best set of predictors of suicide threats.","PeriodicalId":275647,"journal":{"name":"In the Fullness of Time","volume":"47 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"123450443","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2018-10-01DOI: 10.1093/med-psych/9780195370607.003.0001
M. Zanarini
The borderline diagnosis was first described by Alfred Stern in 1938. However, “borderline personality disorder” (BPD) did not enter the official nomenclature of American psychiatry until 1980. Between these two time points, psychoanalysts and psychiatrists carefully described aspects of borderline psychopathology, particularly cognitive symptoms. Two of the most careful and influential descriptions of the borderline diagnosis in the 1960s and 1970s were those of Otto Kernberg, who described the broad concept of borderline personality organization (BPO), and John Gunderson, who described the affective, cognitive, impulsive, and interpersonal symptoms of BPD. After 1980, BPD was often described as being a subthreshold variant of various diagnostic spectrums (e.g., mood disorders, impulsive disorders, trauma disorders) that were in vogue at that time. However, BPD is now commonly accepted as a well-validated disorder with a characteristic symptom profile that distinguishes it from other disorders, including other personality disorders.
{"title":"History of the Borderline Diagnosis","authors":"M. Zanarini","doi":"10.1093/med-psych/9780195370607.003.0001","DOIUrl":"https://doi.org/10.1093/med-psych/9780195370607.003.0001","url":null,"abstract":"The borderline diagnosis was first described by Alfred Stern in 1938. However, “borderline personality disorder” (BPD) did not enter the official nomenclature of American psychiatry until 1980. Between these two time points, psychoanalysts and psychiatrists carefully described aspects of borderline psychopathology, particularly cognitive symptoms. Two of the most careful and influential descriptions of the borderline diagnosis in the 1960s and 1970s were those of Otto Kernberg, who described the broad concept of borderline personality organization (BPO), and John Gunderson, who described the affective, cognitive, impulsive, and interpersonal symptoms of BPD. After 1980, BPD was often described as being a subthreshold variant of various diagnostic spectrums (e.g., mood disorders, impulsive disorders, trauma disorders) that were in vogue at that time. However, BPD is now commonly accepted as a well-validated disorder with a characteristic symptom profile that distinguishes it from other disorders, including other personality disorders.","PeriodicalId":275647,"journal":{"name":"In the Fullness of Time","volume":"53 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"127628582","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2018-10-01DOI: 10.1093/MED-PSYCH/9780195370607.003.0005
M. Zanarini
This chapter describes the 24 symptoms of BPD assessed in this study. It also describes what each symptom may mean to a borderline patient and the best way for clinicians to handle these symptoms. Some of the symptoms studied are affective (depression and sorrow, anger and rage, anxiety and panic, feelings of helplessness, hopelessness, and worthlessness, and feelings of emptiness and loneliness), while others are cognitive (troubling but nonpsychotic problems, such as overvalued ideas of worthlessness and guilt, experiences of depersonalization and derealization, and nondelusional suspiciousness and ideas of reference; quasi-psychotic or psychotic-like symptoms [i.e., transitory, circumscribed, and somewhat reality-based delusions and hallucinations]). Others are impulsive (self-mutilation, suicide threats, suicide attempts), while yet others are interpersonal (manipulation, demandingness, entitlement, treatment regressions, special relationships, dependency and counter-dependency, distortions of the truth, sadomasochistic tendencies).
{"title":"The Symptoms of Borderline Personality Disorder Assessed in MSAD","authors":"M. Zanarini","doi":"10.1093/MED-PSYCH/9780195370607.003.0005","DOIUrl":"https://doi.org/10.1093/MED-PSYCH/9780195370607.003.0005","url":null,"abstract":"This chapter describes the 24 symptoms of BPD assessed in this study. It also describes what each symptom may mean to a borderline patient and the best way for clinicians to handle these symptoms. Some of the symptoms studied are affective (depression and sorrow, anger and rage, anxiety and panic, feelings of helplessness, hopelessness, and worthlessness, and feelings of emptiness and loneliness), while others are cognitive (troubling but nonpsychotic problems, such as overvalued ideas of worthlessness and guilt, experiences of depersonalization and derealization, and nondelusional suspiciousness and ideas of reference; quasi-psychotic or psychotic-like symptoms [i.e., transitory, circumscribed, and somewhat reality-based delusions and hallucinations]). Others are impulsive (self-mutilation, suicide threats, suicide attempts), while yet others are interpersonal (manipulation, demandingness, entitlement, treatment regressions, special relationships, dependency and counter-dependency, distortions of the truth, sadomasochistic tendencies).","PeriodicalId":275647,"journal":{"name":"In the Fullness of Time","volume":"53 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"114436132","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2018-10-01DOI: 10.1093/MED-PSYCH/9780195370607.003.0018
M. Zanarini
At baseline, three defenses were found in multivariate analyses to be significantly associated with a borderline diagnosis. Two of these defenses were immature and one was neurotic: acting out, emotional hypochondriasis (i.e., transformation of feelings of sorrow, rage, and terror into unremitting complaints about the lack of understanding that others display), and undoing. At 16-year follow-up, borderline patients could still be differentiated from Axis II comparison subjects, and improvement was found in many defenses. In addition, four time-varying defense mechanisms were found to predict time-to-recovery. One was mature and three were immature: humor, acting out, emotional hypochondriasis, and projection. The clinical meaning and usefulness of assessing defenses over time, particularly immature defenses, in clinical settings is discussed.
{"title":"Defense Mechanisms over Time","authors":"M. Zanarini","doi":"10.1093/MED-PSYCH/9780195370607.003.0018","DOIUrl":"https://doi.org/10.1093/MED-PSYCH/9780195370607.003.0018","url":null,"abstract":"At baseline, three defenses were found in multivariate analyses to be significantly associated with a borderline diagnosis. Two of these defenses were immature and one was neurotic: acting out, emotional hypochondriasis (i.e., transformation of feelings of sorrow, rage, and terror into unremitting complaints about the lack of understanding that others display), and undoing. At 16-year follow-up, borderline patients could still be differentiated from Axis II comparison subjects, and improvement was found in many defenses. In addition, four time-varying defense mechanisms were found to predict time-to-recovery. One was mature and three were immature: humor, acting out, emotional hypochondriasis, and projection. The clinical meaning and usefulness of assessing defenses over time, particularly immature defenses, in clinical settings is discussed.","PeriodicalId":275647,"journal":{"name":"In the Fullness of Time","volume":"21 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"124916962","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2018-10-01DOI: 10.1093/MED-PSYCH/9780195370607.003.0007
M. Zanarini
Many clinicians are reluctant to treat or actively avoid treating patients with BPD. This is so because of the interpersonal difficulties that tend to arise during such a treatment, and is partly due to the idea that BPD is a chronic disorder. This chapter, however, describes the reason for much of the new optimism about the borderline diagnosis. After 16 years of prospective follow-up, it was found that 99% of borderline patients achieved a two-year remission of their BPD, and 78% achieved an eight-year remission of this disorder. Additionally, recurrences of BPD were relatively infrequent, suggesting that remissions of this disorder were stable in nature. These findings suggest that BPD is a “good prognosis” diagnosis and not the chronic condition that many clinicians still believe.
{"title":"Symptomatic Remissions and Recurrences of the Borderline Diagnosis","authors":"M. Zanarini","doi":"10.1093/MED-PSYCH/9780195370607.003.0007","DOIUrl":"https://doi.org/10.1093/MED-PSYCH/9780195370607.003.0007","url":null,"abstract":"Many clinicians are reluctant to treat or actively avoid treating patients with BPD. This is so because of the interpersonal difficulties that tend to arise during such a treatment, and is partly due to the idea that BPD is a chronic disorder. This chapter, however, describes the reason for much of the new optimism about the borderline diagnosis. After 16 years of prospective follow-up, it was found that 99% of borderline patients achieved a two-year remission of their BPD, and 78% achieved an eight-year remission of this disorder. Additionally, recurrences of BPD were relatively infrequent, suggesting that remissions of this disorder were stable in nature. These findings suggest that BPD is a “good prognosis” diagnosis and not the chronic condition that many clinicians still believe.","PeriodicalId":275647,"journal":{"name":"In the Fullness of Time","volume":"1100 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"122913156","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2018-10-01DOI: 10.1093/med-psych/9780195370607.003.0002
M. Zanarini
This chapter details three theories of the core features of BPD. Linehan has emphasized emotion dysregulation, while Gunderson has focused on problematic attachment. Zanarini has offered a complex model of borderline psychopathology that stresses the interaction between an innate hyperbolic temperament and a kindling event or series of events that results in a full-blown case of BPD. The empirical evidence for environmental factors relevant to the etiology of BPD is also reviewed. The results of studies of adverse childhood experiences are reviewed in detail. The role of separations and losses, disturbed parental involvement, and frank abuse and neglect are each reviewed in detail. The chapter then explores the etiology of the symptom areas of BPD, with both environmental factors and biological factors being considered.
{"title":"Models of the Core Features of Borderline Personality Disorder","authors":"M. Zanarini","doi":"10.1093/med-psych/9780195370607.003.0002","DOIUrl":"https://doi.org/10.1093/med-psych/9780195370607.003.0002","url":null,"abstract":"This chapter details three theories of the core features of BPD. Linehan has emphasized emotion dysregulation, while Gunderson has focused on problematic attachment. Zanarini has offered a complex model of borderline psychopathology that stresses the interaction between an innate hyperbolic temperament and a kindling event or series of events that results in a full-blown case of BPD. The empirical evidence for environmental factors relevant to the etiology of BPD is also reviewed. The results of studies of adverse childhood experiences are reviewed in detail. The role of separations and losses, disturbed parental involvement, and frank abuse and neglect are each reviewed in detail. The chapter then explores the etiology of the symptom areas of BPD, with both environmental factors and biological factors being considered.","PeriodicalId":275647,"journal":{"name":"In the Fullness of Time","volume":"18 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"131615393","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2018-10-01DOI: 10.1093/MED-PSYCH/9780195370607.003.0004
M. Zanarini
This chapter first describes the design and instruments (both semi-structured interviews and self-report measures) used during each subject’s index admission to determine study eligibility and study group assignment. It also details diagnostic and demographic features of both study groups: borderline patients and Axis II comparison subjects. In addition, it details baseline results pertaining to childhood adversity, family history of psychiatric disorder, co-occurring disorders, subsyndromal phenomenology (inner pain and aspects of dissociation), onset of self-mutilation, and psychiatric treatment history prior to study entrance. This introduction to the study and its initial findings sets the background against which our prospective findings occur—findings pertaining to six-year follow-up, 10-year follow-up, and 16-year follow-up.
{"title":"The McLean Study of Adult Development (MSAD)","authors":"M. Zanarini","doi":"10.1093/MED-PSYCH/9780195370607.003.0004","DOIUrl":"https://doi.org/10.1093/MED-PSYCH/9780195370607.003.0004","url":null,"abstract":"This chapter first describes the design and instruments (both semi-structured interviews and self-report measures) used during each subject’s index admission to determine study eligibility and study group assignment. It also details diagnostic and demographic features of both study groups: borderline patients and Axis II comparison subjects. In addition, it details baseline results pertaining to childhood adversity, family history of psychiatric disorder, co-occurring disorders, subsyndromal phenomenology (inner pain and aspects of dissociation), onset of self-mutilation, and psychiatric treatment history prior to study entrance. This introduction to the study and its initial findings sets the background against which our prospective findings occur—findings pertaining to six-year follow-up, 10-year follow-up, and 16-year follow-up.","PeriodicalId":275647,"journal":{"name":"In the Fullness of Time","volume":"232 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"132219277","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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